Development and validation of ischemic heart disease and stroke prognostic models using large-scale real-world data from Japan

BACKGROUND@#Previous cardiovascular risk prediction models in Japan have utilized prospective cohort studies with concise data. As the health information including health check-up records and administrative claims becomes digitalized and publicly available, application of large datasets based on such real-world data can achieve prediction accuracy and support social implementation of cardiovascular disease risk prediction models in preventive and clinical practice. In this study, classical regression and machine learning methods were explored to develop ischemic heart disease (IHD) and stroke prognostic models using real-world data.@*METHODS@#IQVIA Japan Claims Database was searched to include 691,160 individuals (predominantly corporate employees and their families working in secondary and tertiary industries) with at least one annual health check-up record during the identification period (April 2013-December 2018). The primary outcome of the study was the first recorded IHD or stroke event. Predictors were annual health check-up records at the index year-month, comprising demographic characteristics, laboratory tests, and questionnaire features. Four prediction models (Cox, Elnet-Cox, XGBoost, and Ensemble) were assessed in the present study to develop a cardiovascular disease risk prediction model for Japan.@*RESULTS@#The analysis cohort consisted of 572,971 invididuals. All prediction models showed similarly good performance. The Harrell's C-index was close to 0.9 for all IHD models, and above 0.7 for stroke models. In IHD models, age, sex, high-density lipoprotein, low-density lipoprotein, cholesterol, and systolic blood pressure had higher importance, while in stroke models systolic blood pressure and age had higher importance.@*CONCLUSION@#Our study analyzed classical regression and machine learning algorithms to develop cardiovascular disease risk prediction models for IHD and stroke in Japan that can be applied to practical use in a large population with predictive accuracy.

Cardiopatía isquémica. Consideraciones para la atención odontológica / Ischemic heart disease. Considerations for dental treatment

La cardiopatía isquémica es un padecimiento que se caracteriza por la falta de oxígeno del músculo cardiaco y es la principal causa de infarto de miocardio. Existen múltiples factores que predisponen al desarrollo de ésta como la obesidad, la hiperlipidemia, el sedenta- rismo, tabaquismo, diabetes e hipertensión. Dadas las características que configuran la fisiopatología de la cardiopatía isquémica, existen diversas consideraciones que deben ser tomadas en cuenta toda vez que el estomatólogo brinde atención a un paciente con este padecimiento. El objetivo del presente artículo es conocer todo lo relacionado con la fisiopatología de la cardiopatía isquémica, sus manifestaciones clínicas, su tratamiento médico y lo más importante, las consideraciones que deben tomarse en el consultorio dental cuando se atienda a un paciente que padezca esta condición (AU)

Ischemic heart disease is a condition characterized by a lack of oxygen in the heart muscle and is the main cause of myocardial infarction. There are multiple factors that predispose to the development of this, such as obesity, hiyperlipidemia, sedentary lifestyle, smoking, diabetes and hypertension. Given the characteristics that make up the pathophysiology of ischemic heart disease, there are various considerations that must be taken into account whenever the stomatologist provides care to a patient with this condition. The objective of this article is to know everything related to the pathophysiology of ischemic heart disease, its clinical manifestation, its medical treatment and most importantly, the considerations that must be taken in the dental office when caring for a patient with this condition (AU)

Air Temperature Affects the Hospital Admission for Cardiovascular Diseases among Rural Residents in Dingxi City / 中国医学科学院学报

Objective To explore the effect of air temperature on the hospitalization of rural residents with cardiovascular diseases and its lag effect in Dingxi city. Methods The meteorological data and air pollution data of Dingxi city from 2018 to 2019,as well as the daily hospitalization data of rural residents due to cardiovascular diseases,were collected.The distributed lag non-linear models were employed to analyze the relationship between daily mean air temperature and the number of inpatients with cardiovascular diseases.Meanwhile,stratified analysis was carried out according to gender,age,and disease. Results There was a non-linear relationship between air temperature and the number of hospitalized rural residents with cardiovascular diseases in Dingxi city.The exposure-response curve approximated a bell shape.The curves for different cardiovascular diseases appeared similar shapes,with different temperature thresholds.Low temperature(-7 ℃) and moderately low temperature(0 ℃) exhibited a cumulative lag effect on the number of patients hospitalized with cardiovascular diseases.With a cumulative lag of 7 days at -7 ℃ and 14 days at 0 ℃,the RR values peaked,which were 1.121(95% CI=1.002-1.255) and 1.198(95% CI=1.123-1.278),respectively.With a cumulative lag of 14 days at 0 ℃,the RR values were 1.034(95% CI=1.003-1.077) and 1.039(95% CI=1.004-1.066) for the number of hospitalized patients with ischemic heart disease and heart rhythm disorders,respectively.The cumulative lag effects of moderately high temperature(17 ℃) and high temperature(21 ℃) on ischemic heart disease,heart rhythm disorders,and cerebrovascular disease all peaked on that day.Specifically,the RR values at 17 ℃ and 21 ℃ were 1.148(95% CI=1.092-1.206) and 1.176(95% CI=1.096-1.261) for ischemic heart disease,1.071(95% CI=1.001-1.147) and 1.112(95% CI=1.011-1.223) for heart rhythm disorders,and 1.084(95% CI=1.025-1.145) and 1.094(95% CI=1.013-1.182) for cerebrovascular disease,respectively.There was no cumulative lag effect of air temperature on the number of hospitalized patients with heart failure.In addition,stratified analysis showed that low temperature(-7 ℃) and moderately low temperature(0 ℃) affected the number of hospitalized female patients with cardiovascular diseases,and only moderately low temperature(0 ℃) affected males.The cumulative lag effect of high temperature on females was higher than that on males.Air temperature exhibited a stronger impact on female patients than on male patients. Additionally,the population aged<65 years old was more sensitive to low temperature and high temperature than that aged ≥65 years old. Conclusions Air temperature changes increase the hospitalization risk of rural residents with cardiovascular diseases in Dingxi city,which presents a lag effect.The effects of air temperature on patients hospitalized due to cardiovascular diseases varied among different etiologies,genders,and ages.It is necessary to emphasize on the impact of temperature changes on health in residents,especially for key populations such as females,people aged<65 years old,and those with ischemic heart disease.

Evaluación de la eficacia de los protocolos de recuperación mejorada en cirugía cardiaca. Protocolo de Ensayo Clínico Aleatorizado / Assessment of the efficacy of improved recovery protocols in cardiac surgery. Randomized Clinical Trial Protocol

Introducción: Múltiples son los artículos publicados que abordan el tema de la ciencia abierta y su importancia para la sociedad, especialmente para la comunidad de investigadores. Esta constituye, ineludiblemente, el presente y futuro de las revistas científicas como método de expandir las investigaciones con alta calidad y credibilidad. La ciencia abierta como movimiento, tiene varios componentes y dentro de ellos, la gestión de citas y referencias de datos, códigos y materiales, que fundamentan la necesidad de que los autores tengan disponibles los contenidos subyacentes a los artículos que se publican y que constituyen la base de los resultados obtenidos en cada investigación. Objetivo: Evaluación de la eficacia de los protocolos de recuperación mejorada en cirugía cardiaca. Métodos: El protocolo que se propone fue elaborado por la investigadora principal (registro público cubano de ensayos clínicos RPCEC00000304) y se describe acorde a las recomendaciones de la lista internacional de chequeo para ensayos clínicos (SPIRIT). Conclusiones: Estarían en relación a si se puede demostrar, después de terminada la investigación, si el protocolo motivo de la Intervención, es mejor, igual o peor que el protocolo de control(AU)

Introduction: There are multiple articles published that address the subject of open science and its importance for society, especially for the research community. This constitutes, inevitably, the present and future of scientific journals as a method of expanding research with high quality and credibility. Open science, as a movement, has several components including the management of citations and references of data, codes and materials, which support the need for authors to have available the underlying content of the articles published and constituting the base for the results obtained in each investigation. Objective: Assessment of the efficacy of improved recovery protocols in cardiac surgery. Methods: The proposed protocol was prepared by the main researcher (Cuban public registry of clinical trials: RPCEC00000304) and is described according to the recommendations of the international checklist for clinical trials (SPIRIT). Conclusions: They would be related to whether it can be demonstrated, after the end of the investigation, if the protocol reason for the intervention is better, equal to, or worse than the control protocol(AU)

Seguimiento a un año de la revascularización percutánea de oclusiones coronarias crónicas en el Hospital México / One-year follow-up of percutaneous revascularization of chronic coronary occlusions at Hospital México

Resumen La prevalencia de la enfermedad arterial coronaria compleja en la población mundial es alta. Las oclusiones coronarias crónicas totales (OCT) generan gran morbilidad en la población y significan un reto terapéutico por su alta complejidad. En años recientes con el desarrollo de nuevas tecnologías se ha visto a nivel mundial un beneficio en la calidad de vida, síntomas y función sistólica del ventrículo izquierdo al realizar intervención coronaria percutánea (ICP) de las OCT con una alta tasa de éxito y pocas complicaciones. En este trabajo se describen los resultados clínicos cardiovasculares a un año de realizar ICP en pacientes con OCT intervenidos en el Hospital México en Costa Rica durante 2016-2017. Se registraron 54 pacientes con seguimiento de 1 año posterior a ICP de OCT. Se analizaron variables sociodemográficas y clínicas, cuantificando síntomas según la escala funcional de la Asociación de Corazón de Nueva York (NYHA) y la Sociedad Canadiense de Cardiología (CCS) de angina, así como valoración de la fracción de eyección (FE) por ecocardiografía en forma basal y posterior a la ICP, y las complicaciones asociadas De los 54 pacientes sometidos a ICP de OCT, la mayoría fueron hombres con edad promedio de 64 años y nivel académico básico. No hubo diferencia significativa en la FE previo y posterior al procedimiento (p=0.68), con una tendencia a la mejoría en los pacientes con disfunción sistólica severa con tejido viable. Sí hubo diferencias significativas en mejoría de síntomas basados en la escala funcional NYHA (p<0,01) y la escala de angina CCS (p<0,01). Se alcanzó un éxito en el procedimiento en el 96.3% de los casos sin diferencia significativa según el acceso vascular ni la escala J-CTO con una tasa de complicaciones baja. Concluimos que hay un beneficio clínico significativo en cuanto a los síntomas, al revascularizar a pacientes con oclusiones coronarias crónicas totales, con una alta tasa de éxito en el procedimiento y pocas complicaciones.

Abstract There is a high prevalence of complex coronary artery disease worldwide, in this group chronic total occlusions (CTO) generate a great burden of disease in the population and are a difficult therapeutic challenge. In recent years and with the development of new technologies, the world have seen a benefit in quality of life, symptoms and systolic function of the left ventricle when performing a percutaneous coronary intervention (PCI) of CTO with high success rate and low rate of complications. In this study we describe the cardiovascular clinical results one year after performing PCI in patients with CTOs in Hospital Mexico in Costa Rica during 2016-2017. Methods: We registry 54 patients completing one year follow up after PCI of CTO. We measure sociodemographic and clinical variables quantifying symptoms using NYHA and CCS scales, ejection fraction (EF) using echocardiography previous and after PCI, and the complications developed. We identified 54 patients who underwent PCI of CTO, most were men with an average age of 64 years and a basic academic level. There was no significant difference in the pre-and-post-procedure EF (p=0.68), with a trend to improvement in patients with severe left ventricle systolic dysfunction and viable myocardium. There were significant differences in symp- tom improvement based on the NYHA functional status score (p<0.01) and the CCS angina score (p<0.01). A successful procedure was achieved in 96.3% of cases with no significant difference depending on vascular access or the J-CTO scale with low complication rate. Conclusions: There is a significant clinical benefit based on symptoms of performing PCI in patients with CTO with a high success rate in the procedure and a few associated complications.

Trend of mortality from ischemic heart disease and influenza vaccination in older adults in São Paulo / Tendência da mortalidade por doenças isquêmicas do coração e a vacinação contra influenza em idosos em São Paulo

Abstract The aim of the present study was to analyze the mortality trend due to ischemic heart disease (IHD) among older adults, identify changes in the trend and determine the correlation with influenza vaccine coverage (2000 to 2012) in the state of São Paulo between 1980 and 2012. An ecological time series study was conducted involving secondary data from Brazilian information systems. Linear and polynomial regression models as well as joinpoint regression were used to estimate the trends. Pearson's correlation coefficient was used to evaluate the correlation between age-standardized mortality coefficients and vaccine coverage. A decreasing tendency in mortality due to IHD occurred in both sexes, higher mortality rates were found for males and greater reductions were found in the period after the vaccination campaigns. However, no statistically significant changes occurred in the year coinciding with or near the onset of the campaigns. In the overall sample, no evidence of a linear correlation was found between the mortality coefficients and vaccination coverage. Other factors directly associated with morbidity and mortality due to ischemic heart disease may have influenced the trend.

Resumo O objetivo deste artigo é analisar a tendência dos coeficientes de mortalidade por doenças isquêmicas do coração (DIC) nos idosos no estado de São Paulo, entre 1980 e 2012, identificar mudanças na tendência e verificar a relação entre as coberturas da vacinação contra influenza e os referidos coeficientes de mortalidade. Trata-se de um estudo ecológico de série temporal, realizado com dados secundários do Sistema de Informação sobre Mortalidade (SIM), do Instituto Brasileiro de Geografia e Estatística (IBGE) e do Sistema de Informações do Programa Nacional de Imunização. Para análise dos dados, utilizaram-se técnicas de correlação, modelos de regressão linear, polinomial e joinpoint regression. Observou-se tendência de queda dos coeficientes de mortalidade por DIC em ambos os sexos, sobremortalidade masculina e redução mais expressiva dos coeficientes no período após a intervenção vacinal. As mudanças estatisticamente significativas encontradas nas tendências não ocorreram em ano coincidente ou próximo do início das campanhas. Para o total de idosos, não foi constatada correlação linear entre os coeficientes de mortalidade e as coberturas vacinais. Outros fatores associados à morbimortalidade dos idosos por DIC podem ter influenciado na tendência.

Caracterización de los factores de riesgo en pacientes con cardiopatía isquémica Hospital "Mártires del 9 de Abril", período 2016-2017 / Characterization of risk factors in patients with ischemic heart disease. Hospital "Martires del 9 de abril", period 2016-2017

RESUMEN Introducción: las enfermedades cardiovasculares constituyen la principal causa de muerte en la mayoría de los países. Se describen los factores de riesgo para enfermedad coronaria como no modificables: edad, sexo y antecedentes familiares; y modificables relacionados al estilo de vida: tabaquismo, dislipidemia, obesidad, sedentarismo, diabetes, uso abusivo de alcohol y la enfermedad hipertensiva. Objetivo: caracterizar los factores de riesgo asociados a la cardiopatía isquémica en Atención Secundaria de Salud. Materiales y métodos: estudio observacional, descriptivo transversal en pacientes ingresados en el Hospital "Mártires del 9 de Abril" de Sagua la Grande, en el periodo comprendido entre los años 2016 y 2017. Integraron la muestra 96 pacientes que ingresaron con diagnóstico de cardiopatía isquémica. Se describieron las características demográficas de los mismos; fueron identificados los factores de riesgo y se determinó la frecuencia de asociación de otras formas clínicas de ateromatosis. Resultados: los pacientes fueron mayores de 60 años de edad; la mayoría tenían color de la piel blanca; presentaban antecedentes patológicos familiares de cardiopatía isquémica; las principales formas de cardiopatía isquémica fueron: angina e insuficiencia cardiaca; todos los pacientes presentaron uno o más factores de riesgo cardiovascular, los más significativos fueron, hipertensión arterial, tabaquismo aumento de la circunferencia abdominal y personalidad tipo "A". Conclusiones: la mayoría de los pacientes exhibieron alteraciones en el electrocardiograma: descenso del segmento ST, bloqueo de rama izquierda del haz de His y fibrilación auricular; se observó hipertrigliceridemia y se apreció asociación entre enfermedad renal crónica y angina.

ABSTRACT Introduction: cardiovascular diseases are the main cause of death in most of the countries. The risk factors for coronary disease are described as unmodifiable: age, sex and family history; and modifiable related to lifestyle: smoking, dyslipidemia, obesity, sedentary lifestyle, diabetes, abusive use of alcohol and hypertensive disease. Objective: to characterize the risk factors associated to ischemic heart disease in secondary health care. Material and methods: observational, cross-sectional, descriptive study in patients admitted in "Mártires del 9 de Abril" Hospital, Sagua la Grande, between 2016 and 2017. The sample consisted of 96 patients admitted with a diagnosis of ischemic heart disease. Their demographic characteristics were described; the risk factors were identified and the frequency of association of other clinical forms of atheromatosis was determined. Results: the patients were aged more than 60 years; most of them were white people and had family pathological antecedents of ischemic heart disease; the main forms of ischemic heart disease were angina and heart failure; all patients showed one or more cardiovascular risk factors being arterial hypertension, smoking, increase of abdominal circumference and type A personality the most significant ones. Conclusions: the majority of patients showed alterations in the electrocardiogram: ST segment decrease, His bundle left branch blockage and atrial fibrillation; hypertriglyceridemia was observed and there was an association between chronic kidney disease and angina.

Fine particulate matter and ischemic heart diseases inrelation to sex. An ecological time series study

ABSTRACT BACKGROUND: Exposure to some air pollutants is associated with cardiovascular diseases. The objective of this study was to quantify the effect of exposure to fine particulate matter in hospitalizations due to ischemic heart disease and the costs to the healthcare system. DESIGN AND SETTING: Time-series ecological study conducted in Taubaté, Brazil. METHODS: Data on hospitalizations due to ischemic heart diseases (ICD I-20 to I-24) in the municipality of Taubaté (SP), Brazil, among adults of both sexes aged 40 years and over, from August 2011 to July 2012, were obtained from DATASUS. Fine particulate matter (PM2.5) concentrations were estimated from a mathematical model. Poisson regression was used in statistical analyses to estimate the relative risks of exposure to PM2.5 for both sexes and after stratification according to sex. The excess of hospitalizations and consequent excess expenditure for the healthcare system were calculated. RESULTS: There were 1040 admissions, among which 382 had ischemic heart diseases (257 males). Themean PM2.5 concentration was 13.2 µg/m3 (SD = 5.6). Significant effects from exposure were noted 4and 5 days after exposure (lag 4 and lag 5) for both sexes and for male sex; for female sex, the effect was 2 days after exposure (lag 2). There were 59 excess hospitalizations for an increase in PM2.5 concentration of 5 µg/m3 and excess expenditure of US$ 150,000 for the National Health System. CONCLUSIONS: An excess of hospital admissions due to ischemic heart disease, with excess expenditure, was identified consequent to PM2.5 exposure.

Situación futura de la cardiopatía isquémica en el estado de San Luis Potosí: un modelo dinámico predictivo / Future status of ischaemic heart disease in the state of San Luis Potosí: A predictive dynamic model

Resumen Objetivo: Desarrollar un modelo dinámico predictivo para generar y analizar la situación futura de la tasa de incidencia de la enfermedad isquémica del corazón en población de 25 años y mayores en México, en función de la variación en el tiempo de algunos factores de riesgo. Método: Estudio ecológico retrospectivo durante el periodo 2013-2015, en la ciudad de San Luis Potosí (México). Se utilizaron bases de datos secundarias con indicadores oficiales de los 58 municipios que conforman el estado de San Luis Potosí, los cuales corresponden a los años 2000, 2005 y 2010. Se analizaron 8 indicadores a nivel municipio, por medio de los métodos de análisis de componentes principales, modelos de ecuaciones estructurales, modelaje dinámico y software de simulación. Resultados: Fueron extraídos 3 componentes que en conjunto explican el 80.43% de la varianza total de los indicadores oficiales utilizados; el segundo componente tiene un peso de 16.36 unidades que favorecen el incremento de la enfermedad analizada; este componente está integrado solo por el indicador EDAD 60-64 y el escenario esperado del mismo va en aumento. El modelo estructural confirma que los indicadores explican el 42% de la variación de esta enfermedad; los posibles escenarios para los años 2015, 2020 y 2025 son de 195.7, 240.7 y 298, respectivamente, por cada 100,000 habitantes de 25 años y mayores. Conclusiones: Se espera un incremento exponencial en la tasa de incidencia de la enfermedad isquémica del corazón; la edad de 60-64 años se identificó como el factor de riesgo de más peso. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract Objective: To develop a predictive dynamic model to generate and analyse the future status of the incidence rate of ischaemic heart disease in a population of 25 years and over in Mexico, according to the variation in time of some risk factors. Method: Retrospective ecological study performed during the period 2013-2015, in San Luis Potosí City, Mexico. Secondary databases that corresponded to the years 2000, 2005, and 2010, were used along with official indicators of the 58 municipalities of the state of San Luis Potosí. Eight indicators were analysed at municipality level, using principal components analysis, structural equation modelling, dynamic modelling, and simulation software methods. Results: Three components were extracted, which together explained 80.43% of the total variance of the official indicators used. The second component had a weight of 16.36 units that favoured an increase of the disease analysed. This component was integrated only by the indicator AGE 60-64 and the expected stage of it increasing. The structural model confirmed that the indicators explain 42% of the variation of this disease. The possible stages for the years 2015, 2020, and 2025 are 195.7, 240.7, and 298.0, respectively for every 100,000 inhabitants aged 25 and over. Conclusions: An exponential increase in the incidence rate of ischaemic heart disease is expected, with the age of 60-64 years being identified as the highest risk factor. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Factores de riesgo de cardiopatía isquémica en área intensiva municipal. Pedro Betancourt. 2013- 2014 / Risk factors of ischemic cardiopathy in the municipal intensive care area. Pedro Betancourt. 2013-2014

Introducción: la cardiopatía isquémica es un problema de salud que cobra un gran número de vidas y es causa de invalidez en la población mundial. Constituyó en el 2013, la primera causa de muerte en el mundo, en Cuba y en la provincia de Matanzas. Objetivo: cuantificar la presencia de factores de riesgo de cardiopatía isquémica en el AIM del Policlínico Docente Cesáreo Sánchez, en Pedro Betancourt entre los meses de diciembre 2013 a Mayo del 2014. Materiales y Métodos: se realizó un estudio observacional, descriptivo, transversal de 59 pacientes que ingresaron con este diagnóstico entre los meses de diciembre 2013 a Mayo 2014. Se recogieron variables como la edad, sexo, factores de riesgo, formas clínicas de presentación, complicaciones presentadas durante el ingreso y presencia del síndrome metabólico. Resultado: hubo un predominio del sexo masculino y del grupo de edad de 65 y más. La hipertensión arterial y el sedentarismo fueron los factores de riesgo más sobresalientes, así como la angina estable y las arritmias cardíacas como la forma clínica y complicación más frecuente respectivamente. La presencia del síndrome metabólico caracterizó a los pacientes estudiados. Conclusiones: la detección y control oportuno de los factores de riesgo de la cardiopatía isquémica continuara siendo la piedra angular de cualquier estrategia preventiva esencial (AU).

Introduction: the ischemic cardiopathy or ischemic cardiovascular disease is a health problem claiming a great number of lives, being a cause of disability in the world population. In 2013 it was the first cause of death worldwide, in Cuba and in the province of Matanzas. Objective: to quantify the presence of the ischemic cardiopathy risk factors in the municipal intensive area (AIM as abbreviation in Spanish) of the Teaching Policlinic Cesareo Sanchez, in Pedro Betancourt, from December 2013 to May 2014. Materials and methods: a cross-sectional, descriptive, observational study was carried out in 59 patients who entered the area with this diagnosis from December 2013 to May 2014. The collected variables were age, sex, risk factors, clinical forms of presentation, complications during staying, and presence of the metabolic syndrome. Results: the results showed the predominance of the male sex and the age group of 65 years and more. Arterial hypertension and sedentary lifestyle were the most outstanding risk factors, and the stable angina and heart arrhythmias were the most frequent clinical form and complication, respectively. The presence of metabolic syndrome characterized the studied patients. Conclusions: the timely detection and control of the ischemic cardiopathy risk factors is still going to be the cornerstone of any essential preventive strategy (AU).

Sesgo en la estratificación del síndrome coronario agudo al calcular el grace- score con 1ª, 2ª o troponina Δ / Grace score bias in acute coronary syndrome due to use 1th, 2th or troponin Δ

Introducción: el síndrome coronario agudo (SCA) es la primera causa de mortalidad en Colombia. Una estratificación de riesgo errónea, en la sala de emergencias (ER), afecta las intervenciones realizadas y la tasa de eventos adversos cardiovasculares puede ser mayor. El objetivo de esta investigación fue medir la diferencia en el puntaje GRACE y la estratificación del riesgo coronario, utilizando los resultados de las troponinas medidas secuencialmente durante la atención inicial. Metodología: con un diseño descriptivo retrospectivo, se evaluaron los registros clínicos de pacientes tratados por dolor precordial de probabilidad intermedia para SCA, sin indicación de manejo invasivo inmediato, atendidos en la sala de emergencias de una clínica del tercer nivel de Bogotá, durante el año 2017. Se determinó la diferencia entre la puntuación GRACE calculada con la primera troponina (GRACE-1), la segunda troponina (GRACE-2) o la troponina delta (GRACE-delta) [prueba T pareada], y la proporción de pacientes poco estratificados se midió al usar la primera troponina [X2, puntaje Z]. Resultados: se identificaron 44 pacientes en un período de 6 meses. La mayoría hombres con edad mediana de 73 años. El promedio (DE) de los puntajes GRACE-1, GRACE-2 y GRACE-delta, fue de 114.14 (30.73), 115.55 (30.14) y 111.11 (28.79), respectivamente; al comparar GRACE-delta con GRACE-1 y GRACE-2 se identificaron diferencias significativas (p:<0.05). Se identificó un error en la estratificación del riesgo coronario en 10/44 pacientes (22.7%) y 9/44 (20.4%) presentaron sobreestratificación. Conclusión: la estratificación del riesgo coronario con la primera troponina, a diferencia de la troponina delta (ítem no aclarado en las guías), evidenció una sobreestratificación en al menos 20% de los pacientes, estableciendo la necesidad de procedimientos más invasivos y posiblemente hospitalización más prolongada permanecer.

Background: Acute coronary syndrome (ACS) is the first cause of mortality in Colombia. An erroneous risk stratification, in the emergency room (ER), affects the interventions performed and the rate of major cardiovascular adverse events. We measured the difference in GRACE score and stratification of coronary risk, by using the results of troponins measured sequentially during initial care. Methods: With a retrospective descriptive design, clinical records of patients treated for precordial pain of ≥ intermediate probability for ACS were evaluated, without indication of immediate invasive management, attended in the ER of a clinic of the third level of Bogotá, during 2017. De-termined the difference between the GRACE score calculated with the first (GRACE-1), second (GRACE-2) or troponin delta (GRACE-delta [paired T-test], and the proportion of poorly stratified patients was measured when using the first troponin [X2, Z-score]. Results: 44 patients in a period of 6 months were identified. The majority men, older adults, middle age 73 years. The average (SD) of scores GRACE-1, GRACE-2 and GRACE-delta, was 114.14 (30.73), 115.55 (30.14) and 111.11 (28.79), respectively; when comparing GRACE-delta with GRACE-1 and GRACE-2 significant differences were identified (p:<0.05). Error in the stratification of coronary risk was identified in 10/44 patients (22.7%), and 9/44 (20.4%) presented over-stratification. Conclusion: The stratification of coronary risk using the first troponin, unlike the troponin delta (item not clarified in the guidelines), evidenced an over-stratification in at least 20% of the patients, establishing the need for more invasive procedures and possibly longer hospital stay.

Ventajas éticas, tecnológicas y económicas de la perfusión miocárdica en la cardiopatía isquémica / Ethical, technological, and economic advantages of myocardial perfusion in ischemic heart disea

Introducción: La alta prevalencia de la cardiopatía isquémica y el progresivo aumento de la esperanza de vida son factores que están contribuyendo de forma importante a que el dolor torácico constituya en estos momentos uno de los principales motivos de consulta hospitalaria. En Cuba, las enfermedades cardiovasculares representan la primera causa de muerte. Su diagnóstico, puede ser un reto. Objetivo: Presentar las ventajas éticas, tecnológicas y económicas de la perfusión miocárdica en el proceso diagnóstico de la cardiopatía isquémica. Material y Métodos: Fue realizada una búsqueda sistematizada de literatura primaria en bases de datos como Scielo, Sciencedirect y Elsevier. Resultados: En el presente artículo se analizó como problema social de la ciencia, la tecnología y la sociedad los estudios de perfusión miocárdica en la cardiopatía isquémica, teniendo especial atención en las implicaciones sociales, éticas, tecnológicas y económicas. Los estudios de perfusión miocárdica son ampliamente utilizados como métodos funcionales no invasivos para el diagnóstico de enfermedad coronaria. Es una técnica fácilmente realizable, con mínimas complicaciones y efectos secundarios, y en consecuencia con amplia aceptación por los pacientes. Conclusiones: Las investigaciones no invasivas para el estudio de la perfusión miocárdica tienen un lugar bien establecido en el proceso diagnóstico del paciente con cardiopatía isquémica con fines de diagnóstico precoz y estratificación de riesgo con altos índices de sensibilidad, especificidad y reproducibilidad y su incorporación a la práctica social asistencial tiene además sólidos fundamentos bioéticos y económicos(AU)

Introduction: The high prevalence of ischemic heart disease and the progressive increase in life expectancy are important factors contributing to the fact that chest pain is one of the main reasons for hospital consultation. In Cuba, cardiovascular diseases are the leading cause of death. Your diagnosis can be challenging. Objective: To present the ethical, technological and economic advantages of myocardial perfusion in the diagnostic process of ischemic heart disease. Material and Methods: A systematized search of primary literature was carried out in databases such as Scielo, Sciencedirect and Elsevier. Results: In the present article, the studies of myocardial perfusion in ischemic heart disease were analyzed as a social problem of science, technology and society, paying particular attention to the social, ethical, technological and economic implications. Myocardial perfusion studies are widely used as noninvasive functional methods for the diagnosis of coronary heart disease. It is a technique easily performed, with minimal complications and side effects, and consequently with wide acceptance by the patients. Conclusions: Noninvasive investigations for the study of myocardial perfusion have a well established place in the diagnostic process of the patient with ischemic heart disease for the purposes of early diagnosis and risk stratification with high sensitivity, specificity and reproducibility indexes and their incorporation into the social welfare practice also has solid bioethical and economic foundations(AU)

La cardiopatía isquémica en pacientes diabéticos y no diabéticos / Ischemic heart disease in diabetic and non-diabetic patients

Introducción: La cardiopatía isquémica tiene como uno de sus factores de riesgo más importante a la Diabetes mellitus, la cual influye en el pronóstico, tratamiento, severidad, morbilidad y mortalidad de esta enfermedad. Objetivo: Caracterizar la influencia de la Diabetes mellitus en la cardiopatía isquémica. Material y Métodos: Se realizó una revisión bibliográfica sobre la temática. Resultados: La Diabetes mellitus es un factor de riesgo de alta relevancia de la cardiopatía isquémica. Las personas con diabetes corren el mismo riesgo de tener un infarto de miocardio que las personas sin diabetes que ya han tenido uno. Las mujeres diabéticas son más propensas a cardiopatías isquémicas. Existe una mayor frecuencia de Diabetes mellitus en los pacientes portadores de la cardiopatía isquémica con edades entre 45 y 80 años. Conclusiones: La diabetes impone mayor riesgo de padecer cardiopatía isquémica, la hace más precoz, le impone dificultades diagnósticas y mayor riesgo de complicaciones. La diabetes y la cardiopatía isquémica son enfermedades con incidencias y prevalencias que se incrementan con la edad(AU)

Introduction:Ischemic heart disease has Diabetes mellitus as one of its most important factors, because affects the prognosis, treatment, severity, morbidity and mortality of the first one. Objective: To characterize the influence of diabetes mellitus on ischemic heart disease. Material and Methods: A literature review on the subject was conducted. Results: Diabetes mellitus is confirmed as a highly relevant risk factor for ischemic heart disease. People with diabetes are at the same risk of having a myocardial infarction as people without diabetes who have already had one. Diabetic women are more likely to have ischemic heart disease. There is a higher frequency of Diabetes mellitus in patients with ischemic heart disease aged between 45 and 80 years. Conclusions:Diabetes imposes an increased risk of suffering of ischemic heart disease, makes it more precocious, and imposes diagnostic difficulties and greater risk of complications. Diabetes and ischemic heart disease are illnesses with incidence and prevalence that increase with age(AU)

L'ischémie myocardique silencieuse du diabétique au service de diabétologie du CHU de Yopougon Abidjan

objectif: identifier les aspects épidémiologiques et diagnostiques de l'ischémie myocardique silencieuse du diabétique à abidjan.Matériel et Méthode :cette rétrospective et descriptive s'est déroulée sur une année ( du 1er janvier au 31 Décembre 2016) dans le service de consultation d'endocrinologie diabétologie du chu de yopougon. Elle a porté sur l'analyse de 282 dossiers de patients diabétiques de type 2 ayant réalisés un electrocardiogramme de repos. Nous avons pris en compte certains faacteurs de risque cardiovasculaire tels que les dyslipidémies , l'HTA, lamicroalbuminurie, le tabagisme actuel et l'obésité abdominaleRésultats : Sur un total de 282 dossiers, 135 patients avaient un ECG de repos ischémique (47,87%) et 137 patients avaient un ECG de repos normal (48,58%). l'age moyen des patients était dde 56,35 +/- 11,83 ans; la durée d'évolution du diabète était de 11,05 +/- 6,5 ans avec un HBAC moyen de 7,5 +/-1,05 %. Les patients étaient asymptomatiques dans 92,90% des cas. L'association diabète et HTA étaient dans 78% des cas. L'ECG de repos ischémique était associé de facon significative à de nombreux facteurs de risque cardiovasculaires étudiés tels que l'obésité abdominale ( p=0,04);lamicroalbuminurie (p=0,03); le tabac (p=0,01); ladyslipidémie (p=0,02).conclusion:Ce trravail confirme la réalité de l'ischémie myocardique silencieuse chez le diabétique à Abidjan, comme en témoigne la prévalence de 51,41%

Factors associated with subendocardial ischemia risk in patients on hemodialysis / Fatores associados ao risco de isquemia subendocárdica em pacientes em hemodiálise

Abstract Introduction: Bone metabolism disorder (BMD) and vascular dysfunction contribute to excess cardiovascular mortality observed in hemodialysis patients. Vascular dysfunction, a new marker of atherosclerosis, can play a role in this risk. Even though associated with higher mortality in the general population, such vascular evaluation in patients on hemodialysis has not been extensively studied. Methods: In this cross-sectional study, hemodialysis patients were submitted to flow-mediated dilation, subendocardial viability ratio (SEVR) and ejection duration index assessment, in order to estimate the impact of BMD markers on vascular dysfunction. Results: A matched cohort of patients with (n = 16) and without (n = 11) severe secondary hyperparathyroidism (SHPT) was studied. Additionally, time spent under severe SHPT was also evaluated. Patients with severe SHPT had lower SEVR and higher ejection duration index, indicating higher cardiovascular risk. Lower SEVR was also associated to diastolic blood pressure (r = 0.435, p = 0.049), serum 25-Vitamin-D levels (r = 0.479, p = 0.028) and to more time spent under severe secondary hyperparathyroidism (SHPT), defined as time from PTH > 500pg/ml until parathyroidectomy surgery or end of the study (r = -0.642, p = 0.027). In stepwise multiple regression analysis between SEVR and independent variables, lower SEVR was independently associated to lower serum 25-Vitamin-D levels (p = 0.005), female sex (p = 0.012) and more time spent under severe SHPT (p = 0.001) in a model adjusted for age, serum cholesterol, and blood pressure (adjusted r² = 0.545, p = 0.001). Conclusion: Subendocardial perfusion was lower in patients with BMD, reflecting higher cardiovascular risk in this population. Whether early parathyroidectomy in the course of kidney disease could modify such results still deserves further investigation.

Resumo Introdução: Distúrbios do metabolismo ósseo (DMO) e alterações da função vascular contribuem para a elevada mortalidade de pacientes em hemodiálise. A disfunção vascular, um novo marcador de aterosclerose, pode contribuir para este risco. Apesar de associada a aumento de mortalidade na população geral, a avaliação de tal disfunção ainda não foi realizada de modo amplo em pacientes em hemodiálise. Métodos: Neste estudo transversal, pacientes em hemodiálise foram submetidos à avaliação da vasodilatação mediada por fluxo, razão de viabilidade subendocárdica (RVSE) e índice de duração de ejeção, como estimativas de avaliação dos marcadores de DMO sobre disfunção vascular. Resultados: Uma coorte pareada com (n = 16) e sem (n = 11) hiperparatireoidismo secundário (HPTS) grave foi estudada. Adicionalmente, o tempo transcorrido do diagnóstico de HPTS grave também foi avaliado. Pacientes com HPTS grave apresentaram menores valores de RVSE e maiores valores de índice de duração de ejeção, apontando maior risco cardiovascular. Baixa RVSE também foi associada à pressão arterial diastólica (r = 0,435, p = 0,049), níveis séricos de 25-Vitamina D (r = 0,479, p = 0,028) e maior tempo transcorrido desde diagnóstico de HPTS grave, definido como tempo em que o paciente permaneceu com valores de paratormônio superiores a 500 pg/ml até realização de cirurgia de paratireoidectomia ou término do estudo (r = -0,642, p = 0,027). Em regressão logística stepwise entre RVSE e variáveis independentes, menor RVSE foi independentemente associado a menores valores de 25-Vitamina D (p = 0,005), sexo feminino (p = 0,012) e maior tempo transcorrido desde diagnóstico de HPTS grave (p = 0,001) em um modelo ajustado para idade, colesterol sérico e pressão arterial (r2 ajustado = 0,545, p = 0,001). Conclusão: A perfusão subendocárdica foi menor em pacientes com DMO, refletindo o maior risco cardiovascular nesta população. Investigações adicionais são necessárias para definir se a paratireoidectomia precoce no curso da doença renal crônica poderia interferir neste risco.

Identification of coronary heart disease in asymptomatic individuals with diabetes mellitus: to screen or not to screen / Identificación de enfermedad cardiaca coronaria en individuos asintomáticos con diabetes mellitus: Tamizar o no tamizar

Coronary heart disease (CHD) is highly prevalent in patients with diabetes mellitus (DM), and remains the single most common cause of death among this population. Regrettably, a significant percentage of diabetics fail to perceive the classic symptoms associated with myocardial ischemia. Among asymptomatic diabetics, the prevalence of abnormal cardiac testing appears to be high, raging between 10% and 62%, and mortality is significantly higher in those with abnormal scans. Hence, the potential use of screening for CHD detection among asymptomatic DM individuals is appealing and has been recommended in certain circumstances. However, it was not until recently, that this question was addressed in clinical trials. Two studies randomized a total of 2,023 asymptomatic diabetics to screening or not using cardiac imaging with a mean follow up of 4.4 ±1.4 yrs. In combination, both trials showed lower than expected annual event rates, and failed to reduce major cardiovascular events in the screened group compared to the standard of care alone. The results of these trials do not currently support the use of screening tools for CHD detection in asymptomatic DM individuals. However, these studies have important limitations, and potential explanations for their negative results that are discussed in this manuscript.

La enfermedad de la arterias coronarias (EAC) es muy prevalente en pacientes con diabetes mellitus (DM), y continúa siendo la principal causa de muerte en estos pacientes. Desafortunadamente, muchos diabéticos pueden carecer de síntomas de alerta en la presencia de isquemia miocárdica, por lo cual el diagnóstico de EAC puede ocurrir de manera tardía. Estudios observacionales han sugerido que la prevalencia de isquemia miocárdica puede ser alta en diabéticos asintomáticos (10 al 62% según la serie) y la mortalidad es mayor en esos pacientes. Por esto, el uso de pruebas para detección de EAC en el paciente diabético asintomático parece atractivo y es recomendado en ciertas circunstancias. Sin embargo, no fue si no hasta hace poco que dos estudios investigaron el verdadero rol de estas pruebas de manera randomizada. En conjunto, 2,023 pacientes diabéticos asintomáticos fueron aleatorizados a recibir o no una prueba para detección de EAC y fueron seguidos en promedio por 4.4 ±1.4 años. Al final de seguimiento, ambos estudios mostraron menos eventos cardiovasculares de los esperados, y el uso de pruebas para detección de EAC no redujo la tasa de eventos cardiovasculares comparado al no uso de estas pruebas. Los resultados de estos ensayos clínicos no soportan actualmente el uso de estas pruebas en el paciente diabético asintomático. Sin embargo, estos estudios tienen limitaciones importantes, y posibles hipótesis para explicar los resultados que son discutidas en el artículo.

Cystatin C: An Early Marker of Cardiac Complications in Diabetics.

Introduction: Cardiovascular disease is one of the common complications of Diabetes mellitus. Serum Cystatin C level has been suggested as a marker for cardiac complications in diabetes. Material and Methods: We studied serum Cystatin C level in Diabetics to fi nd if correlation exists between cardiac complications and elevated Cystatin C levels. Results: A total of 50 diabetics were studied out of whom 25 had cardiac complications and the rest did not have cardiac complications. No signifi cant diff erence was observed between Serum Cystatin C levels of diabetics with cardiac complications (mean 1∙5±0∙45) and diabetics without cardiac complications (1∙4±0∙46) although Cystatin C levels were found to be elevated in diabetic cases. Conclusion: Keeping in view the signifi cant diff erence (p=0∙000) in Cystatin C levels of healthy and diabetic patients, it is reasonable to accept the importance of Cystatin C as an indicator of diabetes and its associated complications.